NSAIDs in CKD: Are They Safe?

Abstract

The management of pain in patients with chronic kidney disease (CKD) is challenging for many reasons. These patients have increased susceptibility to adverse drug effects due to altered drug metabolism and excretion, and there are limited safety data for use in this population despite a high pain burden. Nonsteroidal anti-inflammatory drugs (NSAIDs) have long been regarded as dangerous for use in patients with CKD because of their risk for nephrotoxicity and thus alternative classes of analgesics, including opioids, have become more commonly used for pain control in this population. Given the well-established risks that opioids and other analgesics pose, further characterization of the risk posed by NSAIDs in patients with CKD is warranted. NSAID use has been associated with acute kidney injury, progressive loss of glomerular filtration rate in CKD, electrolyte derangements, and hypervolemia with worsening of heart failure and hypertension. The risk for these nephrotoxicity syndromes is modified by many comorbid conditions, risk factors, and characteristics of use, and in patients with CKD, the risk differs between levels of glomerular filtration rate. In this review, we offer recommendations for the cautious use of NSAIDs in the CKD population after careful consideration of these risk factors on an individualized basis. Complete author and article information provided before references.

Association of Non‐Steroidal Anti‐Inflammatory Drugs with Kidney Health in Ambulatory Older Adults

“…Most NSAID‐associated kidney injury results from intrarenal hemodynamic dysregulation causing decreased GFR and nephron ischemia. High‐dose or prolonged NSAID exposure as well as volume depletion, renal vasoconstriction, and impaired autoregulation increase risk of injury 11,42 . Owing to a high prevalence of CKD and frequent co‐administration of diuretics, ACE inhibitors, ARBs, and other renin‐angiotensin‐aldosterone system (RAAS) inhibitors, older persons are presumed to be more susceptible to NSAID‐associated kidney injury.…”

“…However, NSAID use is limited by their potential for adverse effects including cardiovascular toxicity, peptic ulcers, and nephrotoxicity 6‐8 . NSAIDs can cause acute kidney injury (AKI), which if severe or prolonged may contribute to the development of chronic kidney disease (CKD), though there is little clarity on the magnitude of these risks and their variability across populations 9‐11 . Despite concerns that older adults are at especially high risk of NSAID nephrotoxicity, their risk of long‐term NSAID‐associated kidney damage remains uncertain 10,12,13 .…”

Kidney damage from nonsteroidal anti‐inflammatory drugs—Myth or truth? Review of selected literature

“…In patients with stable CKD in stage 4, low doses of preparations with short half-lives with appropriate dosing intervals of 5 days or less and close monitoring during the treatment period are required to be used. 33 However, it is too soon to draw a conclusion on the best analgesic agent in patients with CKD. 39…”

“…The negative influence of the long duration of NSAIDs treatment on kidney function was observed in a cohort of children with juvenile idiopathic arthritis 32 . The risk of CKD progression in patients using NSAIDs might be different depending on their initial GFR and comorbidities 33 . Terrill et al found that patients with CKD might be prone to AKI after topical NSAIDs administration 34 .…”

Can NSAIDs Be Used Safely for Analgesia in Patients with CKD?: COMMENTARY

“…Patients must also be willing to participate in close medical follow-up. NSAIDs should likely be avoided in those with prostaglandin-dependent states, including states of uncorrected volume depletion, advanced cirrhosis, decompensated heart failure, or nephrotic syndrome (11). In addition, NSAID therapy should be used cautiously in CKD patients who are prescribed RAAS inhibitors, diuretics, and other hyperkalemia-promoting drugs.…”